Clin Orthop Relat Res (2008) 466:2306–2316
DOI 10.1007/s11999-008-0416-z
SYMPOSIUM: ABJS/C.T. BRIGHTON WORKSHOP ON TRAUMA IN THE DEVELOPING WORLD
The Global Burden of Musculoskeletal Injuries
Challenges and Solutions
Charles Mock MD, PhD, Meena Nathan Cherian MD
Published online: 5 August 2008

The Association of Bone and Joint Surgeons 2008
Abstract Musculoskeletal injuries are a major public
health problem globally, contributing a large burden of
disability and suffering. This burden could be considerably
lowered by implementation of affordable and sustainable
strategies to strengthen orthopaedic trauma care, especially
in low- and middle-income countries. This article sum-
marizes the global burden of musculoskeletal injuries and
provides several examples of successful programs that have
improved care of injuries in health facilities in low- and
middle-income countries. Finally, it discusses WHO efforts
to build on the country experiences and to make progress in
lowering the burden of musculoskeletal injuries globally.
The author certifies that he has no commercial associations (e.g.,
consultancies, stock ownership, equity interest, patent/licensing
arrangements, etc.) that might pose a conflict of interest in connection
with the submitted article.
Presented in part at the ABJS/Carl T. Brighton Workshop on
Musculoskeletal Trauma in Low and Middle Income Countries,
Ahmedabad, India, December 11–14, 2007.
Disclaimer: The authors are staff members of the World Health
Organization. The authors alone are responsible for the views
expressed in this publication and they do not necessarily represent the
decisions or policies of the World Health Organization.
C. Mock (&)
Department of Violence and Injury Prevention and Disability,
WHO, 20 Avenue Appia, 1211 Geneva 27, Switzerland
e-mail: mockc@who.int
M. N. Cherian
Department of Essential Health Technologies, WHO, Geneva,
Switzerland
123
Introduction
Injury has become a major cause of death and disability
globally. This is true in countries at all economic levels.
There is often a misperception that injuries are primarily a
health problem of high-income countries. To the contrary,
injury mortality rates are significantly higher in most low-
and middle-income countries (LMICs). Mortality rates from
injury are higher in LMICs compared with high-income
countries (HICs) (Table 1). This is in part due to rising rates
of injuries from increased use of motorized transport and
also due to less developed trauma care systems [12].
The rates of injury have been coming down in HICs due
to a combination of injury prevention and improved trauma
care. At the same time, rates of injury-related death and
disability have been steadily rising in most LMICs. As the
world’s population primarily lives in LMICs, these trends
have led to increasing rates of injury globally. If current
trends continue, most injury-related causes of death will
rise in their ranking of global disease burden.
For every person who dies from injury, many more are
injured, with temporary or permanent disability. We do not
have as comprehensive global data for these non-fatal
injuries as we do for death. However, the data that we do
have are fairly unanimous and uncontroversial in showing
a huge burden of disability from musculoskeletal injuries.
Some of these data come from individual country studies,
such as a population-based survey that showed that 0.83%
of Ghanaians had an injury-related disability. The vast
majority (78%) of such disabilities were due to extremity
injuries. Such disabilities should be readily amenable to
low-cost improvements in orthopaedic care and rehabili-
tation, in contrast to the more difficult to treat neurological
injuries (head and spinal) that are relatively more frequent
causes of disability in high-income countries [9].
Volume 466, Number 10, October 2008 Global Musculoskeletal Burden 2307

Table 1. Deaths per 100,000 from injury by economic region of the Table 2. The 20 leading non-fatal injuries sustained* as a result of
world [22] road traffic collisions, world, 2002
HIC LMIC Type of injury sustained Rate per Proportion
100,000 of all traffic
Road traffic 13 20 population injuries
Poisoning 2 6
Intracranial injury  (short-termà) 85.3 24.6
Falls 8 6
Open wound 35.6 10.3
Fires 1 6
Fractured patella, tibia or fibula 26.9 7.8
Drowning 2 7
Fractured femur (short-termà) 26.1 7.5
Other unintentional 9 16
Internal injuries 21.9 6.3
Suicide 14 14
Fractured ulna or radius 19.2 5.5
Violence 2 10
Fractured clavicle, scapula or humerus 16.7 4.8
War 0.06 3
Fractured facial bones 11.4 3.3
Total 50 88
Fractured rib or sternum 11.1 3.2
Source: WHO Global Burden of Disease Database, 2002 (version 5) Fractured ankle 10.8 3.1
[22].
Fractured vertebral column 9.4 2.7
HIC = high-income countries; LMIC = low- and middle-income
countries. Fractured pelvis 8.8 2.6
Sprains 8.3 2.4
Fractured skull (short-termà) 7.9 2.3
We do have some global data on non-fatal injuries. For
Fractured foot bones 7.2 2.1
example, the Global Burden of Disease (GBD) study
Fractured hand bones 6.8 2.0
evaluated rates of admission for various non-fatal injuries.
Spinal cord injury (long-term§) 4.9 1.4
It can be seen (Table 2) that the majority of these are
musculoskeletal injuries, including open wounds, fractures, Fractured femur (long-term§) 4.3 1.3
and other types of injuries. As with fatal injuries, such non- Intracranial injury  (long-term§) 4.3 1.2
fatal musculoskeletal injuries mostly affect those living in Other dislocation 3.4 1.0
 
LMICs. The GBD estimated that combined rates of * Requiring admission to a health facility; Traumatic brain injury;
à
extremity injury from falls and road traffic crashes ranged Short term = lasts only a matter of weeks; §Long term = lasts until
from 1000 to 2600/100,000 per year in LMICs compared death, with some complications resulting in reduced life expectancy.
Source: WHO Burden of Disease Study, 2002, version 1 data [22].
with 500/100,000 per year in HICs (e.g. two to five times
Reproduced with permission from World Report on Road Traffic
higher in LMICs) [21]. Injury Prevention [15].
Although we do have some global data on rates on non-
fatal injuries, it is not enough. There are ongoing efforts to
develop better global data on these non-fatal injuries, is building capacities in emergency and essential surgical
including musculoskeletal injuries, through the GBD study. and anesthesia services at existing first referral level health
Despite this large burden of death and disability from facilities.
injury, there has been a grossly inadequate response in As this review is focused on the potential gains that
terms of policy and funding. The amount of funding and could be made by strengthening emergency and essential
effort devoted to injury prevention, trauma and basic sur- trauma and surgical care received by the injured, it is
gical care are miniscule in comparison to other significant instructive to look at existing discrepancies in outcome by
global health problems, such as HIV/AIDS and other region of the world. One study showed that mortality rates
infectious diseases. In part this lack of attention is due to for serious injuries (Injury Severity Score C 9) varied with
the misperceptions that injuries arise from ‘‘accidents’’ that economic status, going from 35% in high-income Seattle,
are due to carelessness and bad luck and thus consequently USA, to 55% in middle-income Monterrey, Mexico, to
little can be done to prevent them. However, a great deal 63% in low-income Kumasi, Ghana. Thus, mortality rates
can be done to successfully lower the rates of injury, by for the seriously injured are nearly twice as high in low-
addressing the spectrum of injury control: (1) improving income settings as in HICs [14]. Each year over 5,000,000
the base of knowledge through research and surveillance; people die from injuries, with 95% of these deaths in
(2) improving safety and implementing scientifically-pro- LMICs [7]. If we could eliminate the disparities in injury
ven injury prevention strategies; (3) strengthening outcome among those who are seriously injured and bring
prehospital trauma care; and (4) strengthening hospital- down injury case fatality rates in LMICs from their current
based trauma care, including emergency surgical care and high rates to the rates in HICs, we could potentially save
long-term rehabilitation. A necessary component of item 4 2,000,000 lives per year. If injury mortality rates could

123
2308 Mock and Cherian
even be brought down by a more conservative 8%, 400,000
lives could be saved each year [17].
Case Studies of Successful Programs from Individual
Institutions
Despite the fact that resources in most LMICs are very
limited, many individuals and institutions have reported
innovative solutions to improve the outcomes of trauma
care, oftentimes working in very difficult circumstances.
There are many such examples to report. This section will
point out just a few illustrative examples.
In Mexico, increased number of ambulance stations (to
allow more rapid dispatch) decreased the response times to
reach injured victims. Improved training (in more regular
use of the Prehospital Trauma Life Support Course) led to
improved process of care in the field. The net result was a
decrease in mortality from 8.2% to 4.7%, among trans-
ported trauma patients. These improvements resulted in a
16% increase in the ambulance service budget. However,
this was sustainable within the local economy and these
changes have been institutionalized and maintained by the
local government [3].
In Trinidad, regular use of continuing medical education
for trauma care (in the Advanced Trauma Life Support
Course) resulted in significant improvements in the use of
appropriate treatments for severely injured patients and a
decrease in the mortality of severely injured patients at the
main hospital in Trinidad, from 67% to 34% [1].
In Thailand, the main trauma hospital in Khon Kaen
instituted a trauma audit committee to better oversee
trauma care. This committee identified a high rate of pre-
ventable (e.g. medically preventable) deaths. It identified
several correctable problems, such as inadequate resusci-
tation for shock, delayed surgery for head injuries, and
problems with record keeping and communications. Low
cost, corrective action was instituted to target these prob-
lems, including improved communication within the
hospital by use of radios, better supervision of junior
doctors through increased senior staffing in the ED
(Emergency Department) at peak times, and improved
reporting and monitoring of trauma cases at hospital
meetings (e.g. better use of techniques of quality
improvement). These improvements resulted in a decrease
in mortality among all admitted trauma patients from 6.1%
to 4.4% [5].
In Malawi, one hospital instituted a protocol for open
fractures that emphasized primary external fixation,
scheduled sequential débridement, coverage of exposed
bone through local muscle flaps, controlled secondary
healing, and early mobilization, all low-cost techniques
that could be practiced well in the local circumstances and
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Clinical Orthopaedics and Related Research
within the economic resources available. They reported
recovery of normal function in 80% of patients, functional
results similar to those from HICs [4].
These are obviously just a few brief examples. Many of
the readers of CORR have similar success stories to report
on from their own institutions. The question now is how to
build on such individual institution experiences and make
progress globally.
Global Efforts to Improve Trauma Care
The WHO has several mutually complimentary efforts to
strengthen care of the injured globally, especially in
LMICs. Care of the injured is built on a firm foundation of
adequate surgical and anesthetic capabilities. Hence, the
first one of these programs involves efforts to strengthen
such capabilities, especially in small, rural hospitals, where
resources are most constrained. This program has been
notable in the development of training modules that are
widely used in these resource constrained health facilities.
The second of the WHO efforts emphasizes the develop-
ment of policies to promote stronger trauma care systems,
including both prehospital and facility based care. Thirdly,
a recent resolution by the World Health Assembly has
given added political endorsement to efforts to strengthen
trauma care globally.
Global Initiative for Emergency and Essential Surgical
Care
Musculoskeletal injuries needing urgent care are often
amongst the commonest conditions at the first referral
health facilities (health centers, district, rural or community
hospitals). Often these facilities lack specialists such as
orthopaedic and trauma surgeons, general surgeons, anes-
thesiologists, and emergency physicians. These conditions
require timely emergency, and essential surgical and
anesthesia interventions to reduce death and disability.
At these primary healthcare facilities the urgent care is
usually provided by nonspecialist doctors, nurses, clinical
officers/technicians, and paramedics. Often these caregiv-
ers work in very difficult, isolated circumstances, with
limited equipment and supplies, with limited capability for
urgent referral to more specialized centers, and with lim-
ited opportunity for continuing medical education. In order
to help strengthen surgical care at such locations, WHO has
responded by establishing the Clinical Procedures Unit in
the Department of Essential Health Technologies. This unit
was created to address the deficiencies in the provision of
emergency and essential surgical care, including care of
musculoskeletal injuries, as well as other surgically
Volume 466, Number 10, October 2008
treatable conditions such as infections, pregnancy-related
complications, acute abdominal conditions, and congenital
anomalies.
WHO developed an Integrated Management for Emer-
gency and Essential Surgical Care toolkit (IMEESC) [23]
toolkit based on the WHO reference manual Surgical Care
at the District Hospital [24]. The Emergency and Essential
Surgical Care (EESC) Project employs an integrated
comprehensive training package, the IMEESC toolkit,
aimed at building capacities for health care providers in
resource constrained settings, through ‘‘training of train-
ers’’ workshops held in collaboration with the Ministry of
Health, supported by both local and international partners
(Fig. 1).
Programs have been initiated in 24 countries: Mongolia,
Vietnam, Philippines; Bangladesh, DPR Korea, India, Mal-
dives, Nepal; Kyrgyzstan, Tajikistan; Afghanistan, Oman;
Pakistan; Guyana; Ethiopia, Cote d’Ivoire, Gambia, Ghana,
Kenya, Malawi, Mozambique, Tanzania, Uganda, Zambia;
workshop reports are available at www.who.int/surgery.
The workshops utilize various methods for information
transfer including lectures, role playing, ‘‘hands on’’ skills,
Fig. 1 The Emergency and Essential Surgical Care training work-
shop being held as joint undertaking of Ministry of Health and WHO
in Tanzania is shown. Such collaborative training workshops have
been held in 24 countries.
Global Musculoskeletal Burden 2309
local adaptations of training materials and e-learning ses-
sions. Teaching materials include the WHO IMEESC
toolkit, and the WHO reference manual Surgical Care at
the District Hospital. Orthopaedic components of this
toolkit and program include teaching power point slides,
guidelines in disaster management, emergency and trauma
care, splinting and casting techniques, closed treatment of
fractures, management of open fractures and soft tissue
wounds, and techniques for traction. In addition for a
comprehensive package applicable to a first level referral
health facility, some components are relevant to musculo-
skeletal injuries such as hand washing, antibiotic and
tetanus prophylaxis, medical records, patient consent,
sterilization of equipment, wound management, protocols
on safe anesthesia and surgical procedures, prevention of
HIV, postoperative care, and pain relief.
The WHO IMEESC toolkit includes training videos on
management of wounds and fractures in adults and chil-
dren. It provides guidance to decision makers on policies,
needs assessment, minimum standards to improve essential
surgical and anesthesia care, anesthesia infrastructure and
supplies at various levels of care, training curriculum, and
quality assurance through monitoring and evaluation. It
also includes an inventory tool for emergency essential
equipment for resuscitation (Table 3) which is a basic list
and which can be supplemented with specific lists for
trauma, obstetrics, and other surgical procedures.
In December of 2005, a Global Initiative for Emergency
and Essential Surgical Care (GIEESC) was launched with
the goal of fostering collaboration amongst stakeholders to
promote the delivery of safe and appropriate emergency,
surgical and anesthesia services at resource limited health
care facilities. Key components of the GIEESC include
strengthening capacities through training and education,
supporting policy and implementation of EESC, advocacy,
research, and the development and dissemination of
appropriate technologies for primary health facilities in
resource challenged environments. People interested in
GIEESC may find more information on the project’s
website at: http://www.who.int/surgery/globalinitiative/en/.
Strengthening Trauma Care Systems
Several years ago, WHO’s Department of Violence and
Injury Prevention and Disability Department came out with
two sets of recommendations, primarily oriented at the
policy and Ministry of Health planning level, on ways to
strengthen care of the injured, in both prehospital and
hospital based settings. Prehospital Trauma Care Systems
[18] gives recommendations on ways to institute formal
Emergency Medical Services (EMS) e.g. usually encom-
passing ambulance systems. It also discusses what to do in
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2310 Mock and Cherian Clinical Orthopaedics and Related Research

Table 3. Emergency equipment and supplies for resuscitation (www.who.int/surgery/publications/imeesc/en/index.html)

Capital outlays Quantity Date checked Renewable items Quantity Date checked

Resuscitator bag valve & mask (adult) Suction catheter sizes 16 FG

Resuscitator bag valve & mask (paediatric) Tongue depressor wooden disposable
Oxygen source: cylinder/concentrator Nasogastric tubes 10 to 16 FG
Mask & tubing to connect to oxygen supply Light source (lamp & flash light)
Stethoscope Intravenous fluid infusion set
Batteries for flash light IV cannula sizes 18, 22, 24
Suction pump (manual or electric) Scalp vein infusion set
Blood pressure measuring equipment Syringes 2 ml
Thermometer Syringes 10 ml
Scalpel handle with blade Disposable needles # 25, 21,19
Retractor Sharps disposal container
Scissors straight 12 cm Tourniquet
Scissors blunt 14 cm Sterile gauze dressing
Oropharyngeal airway (adult size) Bandages sterile
Oropharyngeal airway (paediatric) Adhesive Tape
Forcep Kocher no teeth Needles, cutting & round bodied
Forceps, artery Suture synthetic absorbable
Kidney dish stainless steel Splints for arm, leg
Capped bottle, alcohol based solutions Towel cloth
Gloves (sterile) sizes 6 to 8 Absorbent cotton wool
Gloves (examination) small, medium, large Urinary catheter Foleys disposable
#12, 14, 18 with bag
Needle holder Sheeting, plastic PVC clear
Sterilizer Waste disposal container
Nail brush, scrubbing surgeon’s Face masks
Vaginal speculum Eye protection
Bucket, plastic Apron, utility plastic reusable
Drum for compresses with lateral clips Soap
Examination table Wash basin
Inventory list of equipment/supplies for Best practice guidelines available
resuscitation at point of care
Supplementary equipment for use by Supplementary equipment for use
skilled health professionals by skilled health professionals
Magills Forceps (paediatric) Laryngoscope handle
Magills Forceps (adult) Laryngoscope Macintosh blades
(adult)
Endotrachael tubes uncuffed sizes 3.0 to 5.0 Laryngoscope Macintosh blades
(paediatric)
Endotrachael tubes cuffed sizes 5.5 to 9 Spare bulbs, batteries for
laryngoscope
IV Infusor bags Stylet for Intubation
Chest tubes insertion equipment Cricothyroidotomy set

circumstances where this is not affordable or possible, such
as by building on the existing, albeit informal, system of
prehospital care and transport. This can include better
organizing, training, and equipping first responders, such as
police, fire service, and members of the lay public.
In terms of care at fixed facilities, including clinics and
hospitals, WHO has worked collaboratively for several years
with the International Society of Surgery on the Essential
Trauma Care Project. This project has sought to set reason-
able, affordable, minimum standards for trauma care

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services worldwide and to define the resources necessary to
actually provide these services even in the lowest-income
countries. A basic theme of the project is that considerable
improvements in trauma care and its outcome can be
achieved through improved organization and planning at a
minimal increase in cost. Finally, this project seeks to actu-
ally catalyze such improvements in countries worldwide.
A milestone of the project has been the release several
years ago of the publication Guidelines for Essential
Trauma Care [10]. This publication lays out 11 core
essential trauma care services which WHO and the Inter-
national Society of Surgery feel that every injured person
in the world could realistically be able to receive (Table 4).
These include services that would be considered so
straightforward that one may wonder why we should bother
to state them so explicitly. The reason is that a great many
trauma patients worldwide and, possibly, tragically, the
majority, do not receive these services currently and we
feel that they can and should.
In order to assure the availability of these services, the
Guidelines delineates 260 individual items of human
resources (skills, staffing and training) and physical
resources (equipment and supplies) that should be consid-
ered either essential or desirable at the range of health
facilities globally, ranging from rural clinics to tertiary care
facilities (Table 5). Items that are essential (E) are those
that are the most cost-effective and could realistically be
provided to all injured persons treated at that level of the
health care system anywhere in the world, even in the
lowest income countries. Items that are desirable (D) are
those that increase the likelihood of successful outcome,
but are not as universally affordable as essential items.
They are more applicable to middle-income countries or to
very busy trauma care facilities in any location. These
resource tables are intended to be a flexible matrix to be
adjusted by planners in ministries of health or administra-
tors and clinicians in individual hospitals to meet the local
needs of the country or facility.
A key point to be emphasized is that the essential items
should not just be physically present. Essential resources
and services should actually be provided to all who need
them in a timely fashion, without regard of ability to pay.
Having a piece of equipment cannot be said to have met
essential status if the equipment is nonfunctional for long
periods of time while awaiting repairs, nor if it is unused
due to insufficient staffing during periods of time (e.g.
nights and weekends) when most injured patients need it.
Having medications or other supplies in stock cannot be
said to have met essential status if their use depends on
payment in advance, a stipulation which many of the
injured cannot meet. These stipulations do not rule out the
need for billing or cost-recovery later, after essential items
of care have been rendered. However, cost-recovery should
not prevent rendering such essential care.
The Guidelines for EsTC cover the breadth of trauma
care, including initial resuscitation, acute definitive care of
injuries to specific body regions, and long-term rehabilita-
tion. In general terms some of the types of services that the
Guidelines seeks to promote, include, for the circumstances
of low-income countries, such as in Africa and South Asia:
• Primary health care clinics (basic level) should have
capabilities for rapid basic first aid, which many
currently do not have. Though usually having only
very basic capabilities, many of these facilities do
receive a considerable number of injured persons, either
due to the clinics’ locations on major roadways or due
to their geographical isolation and thus lack of any
other health facilities in their vicinity.
• General practitioner (GP) staffed hospitals should have
capabilities for chest tube insertion, airway mainte-
nance and certain minimum blood transfusion
capabilities, which many do not have.
• Specialists and tertiary care facilities should have
capabilities for advanced airway management, includ-
ing emergency endotracheal intubation, which many do

Table 4. Essential trauma care services [10]

• Obstructed airways are opened and maintained before hypoxia leads to death or permanent disability.
• Impaired breathing is supported until the injured person is able to breathe adequately without assistance.
• Pneumothorax and haemothorax are promptly recognized and relieved.
• Bleeding (external or internal) is promptly stopped.
• Shock is recognized and treated with intravenous (IV) fluid replacement before irreversible consequences occur.
• The consequences of traumatic brain injury are lessened by timely decompression of space occupying lesions and by prevention of secondary
brain injury.
• Intestinal and other abdominal injuries are promptly recognized and repaired.
• Potentially disabling extremity injuries are corrected.
• Potentially unstable spinal cord injuries are recognized and managed appropriately, including early immobilization.
• The consequences to the individual of injuries that result in physical impairment are minimized by appropriate rehabilitative services.
• Medications for the above services and for the minimization of pain are readily available when needed.

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2312 Mock and Cherian Clinical Orthopaedics and Related Research

Table 5. Airway management: one of the 14 resource matrices in Guidelines for Essential Trauma Care [10]
Facility level*
Basic GP Specialist Tertiary

Airway: knowledge & skills

Assessment of airway compromise E  E E E
Manual manoeuvres (chin lift, jaw thrust, recovery position, etc.) E E E E
Insertion of oral or nasal airway D E E E
Use of suction D E E E
Assisted ventilation using bag–valve–mask D E E E
Endotracheal intubation D D E E
Cricothyroidotomy (with or without tracheostomy) D D E E
Airway: equipment & supplies
Oral or nasal airway D E E E
Suction device: at least manual (bulb) or foot pump D E E E
Suction device: powered: electric/pneumatic D D D D
Suction tubing D E E E
Yankauer or other stiff suction tip D E E E
Laryngoscope D D E E
Endotracheal tube D D E E
Oesophageal detector device D D E E
Bag–valve–mask D D E E
Basic trauma pack D E E E
Magill forceps D D E E
Capnography I D D D
Other advanced airway equipment I D D D
* Basic: outpatient clinics, often staffed by non-doctors; GP: hospitals staffed by general practitioners; Specialist: hospitals staffed by specialists,
usually including a general surgeon; Tertiary: tertiary care hospitals, often university hospitals, with a wide range of specialists.  Items in the
resource matrices are designated as follows: E: essential; D: desirable; I: irrelevant (not usually to be considered at the level in question, even
with full resource availability).
Reproduced with permission from Guidelines for Essential Trauma Care [10].

not have. These large hospitals should also have quality The true value of the Guidelines lies in its actually
improvement or medical audit programs in place, catalyzing improvements of the care of the injured and
which few currently do. examples of progress in several countries are given in
Table 6.
Similar recommendations pertain to middle-income set-
As mentioned, several countries have undertaken needs
tings, such as Latin America, but desirable items figure
assessments of trauma care capabilities using the criteria
more prominently.
from the Guidelines as a template [2, 11, 16, 19, 20]. These
The Guidelines is intended to be part planning guide for
needs assessments give some idea of priorities for ways in
ministries of health or individual facilities and part advo-
which care of musculoskeletal injuries could be strength-
cacy document to be used by whoever wishes to push for
ened (Table 7). In this survey of 100 institutions in 4
improvements in trauma care. The legitimacy of this doc-
countries, resources for trauma care capabilities were
ument for such advocacy is increased by the fact that it was
assessed. These included human resources (staffing, skills,
created by the two bodies in the world that have the most
training), physical resources (equipment, supplies) and
credibility to do so, WHO and the International Society of
administrative mechanisms. The capabilities for care of
Surgery, as well as by the fact the Guidelines was created
musculoskeletal injuries are summarized (Table 7). In
with the review and other input of an additional thirteen
terms of human resources, large hospitals were fairly well
organizations, including a variety of international subspe-
supplied with fully trained orthopaedic surgeons, except in
cialty organizations (such as Orthopaedics Overseas and
Africa, where general surgeons do most of the orthopaedic
SICOT), as well as, several national organizations (such as
work. At small hospitals, only those in the middle country
the Academy of Traumatology of India).

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Table 6. Examples of progress in implementing the Guidelines for Essential Trauma Care in several individual countries [10]
Ghana • Guidelines endorsed by Ghana Medical Association.
• Nationwide needs assessment conducted using Guidelines as basis [16].
• High profile stakeholders conference held June, 2005. This adapted the Guidelines to Ghanaian circumstances and emphasized
implementation methods. It brought together trauma care professionals, Ministry of Health planners, WHO personnel, and several
members of Parliament.
• The meeting concluded with the development of a document: ‘‘Recommendations for a National Policy on Strengthening the Care
of Injured Persons in Ghana.’’
India • India became one of the first ‘‘early innovators’’ to use the Guidelines. A stakeholders conference was conducted (2003) to adapt
Guidelines to Indian circumstances, where there are five, rather than four, levels and to discuss implementation strategies. These
are cosponsored by government and WHO. Stakeholders involved include trauma care clinicians from government and private
sector, non-government organizations, public health planners, and others.
• The above meeting also stimulated an expanded, nationwide meeting in 2005 entitled, ‘‘First National Consultation Meeting on
Trauma System Development in India,’’ which expanded the essential trauma care concept to a nationwide scale and also
incorporated planning for prehospital services.
• Guidelines used as basis for needs assessments of trauma care capabilities in Gujarat state [11].
Mexico • Guidelines endorsed by Mexican Association for the Medicine and Surgery of Trauma (AMMCT).
• Nationally representative needs assessment conducted using Guidelines as basis under aegis of AMMCT and WHO county office
[2, 11].
• Stakeholders conference conducted (2004) to adapt Guidelines to Mexican circumstances. This was sponsored by national Ministry
of Health and WHO. Stakeholders included presidents or representatives of most national professional societies that deal with
trauma and critical care, as well as ministry of health planners.
• The Guidelines has been translated into Spanish and re-published for use in Latin America.
Vietnam • Guidelines used as basis for needs assessments of trauma care capabilities in several provinces.
• Findings of these needs assessments prompted low-cost improvements in trauma care in Hanoi area [19], an excellent example of
how the Guidelines can be used to stimulate on-the-ground improvements in trauma care.
• Guidelines has been translated into Vietnamese as collaborative effort of WHO country office and Vietnamese Ministry of Health,
and re-published locally, as has the Prehospital Trauma Care Systems.

Mexico have partial coverage by orthopaedists. At other
small hospitals, either general surgeons or general practi-
tioners provide care for musculoskeletal injuries. Even
coverage by general surgeons is partial. At clinics, mostly
care is provided by GPs, and a substantial amount by
nurses and other nondoctor providers.
With nonspecialists providing much of the orthopaedic
and other trauma and surgical care, continuing education
courses become an important opportunity to strengthen
such care, especially at first level health care facilities. All
four countries had such courses available, such as
Advanced Trauma Life Support in Mexico, National
Trauma Management Course in India, or other similar
locally developed courses in the other countries. However,
coverage by such courses was very much suboptimal. In
rural clinics, no one had such training. In small hospitals,
far less than 50% of front line trauma care providers (e.g.
doctors working in the ED or surgeons taking trauma call)
had such training. Even in large hospitals, in most coun-
tries, less than 50% of front line trauma care providers had
such training. The situation for continuing education for
nurses was even lower.
Although ratings for such acute and definitive care
showed some need for improvement, the situation with
rehabilitation was even more difficult. Ratings showed
significant deficiencies in the availability of human
resources for rehabilitation, whether fully trained physician
specialists or other providers such as physical therapists
(PT), were considered. PT coverage was especially limited
in availability at small hospitals.
In terms of physical resources for care of extremity
injuries, fundamental items of orthopaedic trauma care
were fairly well supplied at big hospitals. Portable X-ray
was limited. Capabilities at small hospitals were much
more limited. Related to the previously noted shortages
of human resources for rehabilitation, availability of
prosthesis for amputees was extremely limited at all
levels.
Regarding the deficiencies noted for physical resources,
often the problems were not the presence or absence of the
equipment, but periods of inoperation while waiting for
repairs, lack of supplies (such as film), or requirements for
payment in advance before receiving services, which lim-
ited the availability of diagnostic tests to all who needed
them. There were several instances in which mismatch of
human and physical resources decreased availability of
some services. For example, in India, several small hos-
pitals had functioning X-ray machines and trained staff.

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Table 7. Resources for management of musculoskeletal injuries at 100 facilities in four countries: G: Ghana; V: Vietnam; I: India; M: Mexico
[2, 11, 16, 19, 20]
Type of resource Clinic Small hospital Large hospital
G V I M G V I M G V I M
Number of facilities evaluated 4 14 28 5 8 8 14 4 2 5 1 7

Human resources: acute care

Nurse in emergency department 2 3 2 3 2 3 2 2 2 3 3 2
Doctor for emergency call* 0 1 1 2 2 3 3 3 3 3 3 3
General surgeon* na na na na 1 2 1 2 2 3 3 3
Orthopaedic surgeon* na na na na 0 0 0 2 0 3 3 3
Anesthetist/anesthesiologist* na na na na 2 3 1 3 3 3 3 3
CE course for doctors  na 0 0 0 1 1 0 1 1 1 1 2
CE course for nursesà 0 0 0 0 0 1 0 1 0 1 0 1
Human resources: rehabilitation
Specialized rehabilitative nursing na na na na na na na na 0 1 0 2
Physical therapy na na na na 1 1 0 1 1 3 1 2
Physical medicine and rehabilitation specialist na na na na na na na na 0 2 1 2
Physical resources: extremity injury
Skeletal traction na na na na 1 1 0 1 2 3 3 3
External fixation na na na na 0 1 0 1 1 3 3 2
Internal fixation na na na na 0 2 0 1 1 3 3 2
X-ray na na na na 1 2 2 3 2 3 3 3
Portable X-ray na na na na 1 0 0 1 2 1 2 3
Image intensification§ na na na na 0 0 0 0 0 1 1 1
Limb prosthetics na na na na 0 0 0 0 0 0 0 1
Physical resources: wound care
Skin grafting na na na na 1 2 1 2 2 3 3 3
Tetanus prophylaxis (toxoid and anti-serum) 1 2 2 2 3 3 3 3 3 3 3 3
Administrative functions
Trauma-related quality improvement program na na na na na na na na 0 0 0 0
Trauma cases integrated into broader quality improvement programs 0 1 0 0 0 2 0 1 1 2 1 1
Trauma registry with severity adjustment na na na na na na na na 0 0 0 0
Adequacy of resource based on Guidelines for Essential Trauma Care [10] assessed as: NA (not applicable for that level); 0 (absent); 1
(inadequate, available to less than 50% of those who need it); 2 (partly adequate, available to greater than 50%, but not everyone who needs it); 3
(adequate, available to virtually everyone who needs it).
Facility descriptions: Clinic: usually outpatient facility, but, some with significant volumes of trauma, especially those located along busy roads
in more remote rural areas; Small hospital: in Africa called district, in India called community health centre. Usually performing some type of
surgery, but with more limited range of specialist. Usually with around 50 – 200 beds; Large hospital: provincial, regional, with at least one or
more category of specialist, usually over 200 beds, not including tertiary care centers.
* Available 24 hours per day, 7 day per week in hospital or promptly available on call from home;  Continuing Education (CE) course on trauma
care, such as Advanced Trauma Life Support, National Trauma Management Course, or local equivalent: ideal is that all doctors who provide
first line trauma care in emergency department and all general surgeons who provide trauma care are credentialed in such an in-service training
course; àContinuing Education (CE) course on trauma care, such as Trauma Nursing Core Course or local equivalent: ideal is that all nurses who
provide first line trauma care in emergency department are credentialed in such an in-service training course; §Equipment that is categorized as
‘‘desirable’’ rather than ‘‘essential’’ in the Guidelines for EsTC.

However, the facilities were greatly limited in the number
of plates (films) which they received each month. Thus
many persons needing X-rays did not receive this service.
In Ghana, one large hospital had an image intensifier (C-
arm). However, there were no staff trained to use it and the
machine lay idle. Many such problems are prime targets for
improvement through strengthened organization and plan-
ning [11].
In all settings, there was a dearth of administrative
functions to assure quality trauma care, including trauma
registries, trauma-related quality improvement (medical
audit) programs.

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This study and the broader Essential Trauma Care
Project have identified several specific ways in which
trauma care could be improved in an affordable and sus-
tainable fashion. Much is being done well by many
dedicated people working hard to confront the resource
restrictions in their own environments. There are several
ways in which their efforts could be aided. Several
important, low-cost resources could be better provided at
clinics/small hospitals in middle-income countries and at
most facilities in low-income countries. More generally, in
all settings, training and organization of trauma care could
be improved, including such items as regular in-service
training. Every country should define a core set of essential
equipment and supplies (including those needed for mus-
culoskeletal injury) and then assure and monitor the
availability of such resources to all who need them. This is
what is recommended by the Guidelines for Essential
Trauma Care, which offers the first internationally-appli-
cable standard for countries to use to assess their trauma
systems. In so doing, the Guidelines offers a way to pro-
mote realistic, minimum standards for trauma care, in a
comprehensive fashion worldwide.
World Health Assembly (WHA) Resolution on Trauma
and Emergency Care Services
In an effort to promote greater efforts to strengthen trauma
care, the WHA last year (2007) passed a resolution on
trauma and emergency care services: WHA 60.22: ‘‘Health
systems: emergency care system.’’ The WHA is the gov-
erning board of the WHO. It consists of Ministers of Health
of all 193 Member States. Its resolutions direct WHO’s
activities and carry considerable influence on actions of
individual countries, as well as non-government organiza-
tions and funders. Last year, it passed for the first time ever
a resolution encouraging governments worldwide to
increase their efforts at providing care for trauma and other
emergency conditions. The resolution listed 10 actions that
Member States could take to achieve this, including mea-
sures like: ‘‘Identifying a core set of trauma services and
developing methods to assure and document that such
services are provided to all who need them.’’ The full
text of the resolution is available in all six UN languages
on the WHO website at: www.who.int/gb/ebwha/pdf_files/
WHA60/A60_R22.en.pdf.
The resolution adds political endorsement to what many
CORR readers have been working on for years. Clinicians
active with care of the injured or anyone who wishes to
promote improvements in care of the injured in their area
can make use of this resolution by taking some of the
following steps:
Global Musculoskeletal Burden 2315
1. Making sure your ministries of health are aware of this
resolution. It has been adopted by all 193 WHO
Member States. Hence, in theory, it has the support of
governments everywhere. However, this support var-
iably filters down to the level of those who are making
decisions on resources available for trauma care
services. Appropriately bringing this resolution to their
attention and indicating that the country’s government
supported it can help to increase political commitment
for strengthening trauma care services.
2. Making sure that your Ministry of Health and local
WHO office are aware of the expertise that you and
your organizations have towards implementing this
resolution.
3. Disseminating information about this resolution in
your newsletters, journals, websites.
4. Pointing out, especially to donors and funders, how
your activities are in keeping with the recommenda-
tions of this resolution. Many donors do take notice of
WHA resolutions [8, 13].
In conclusion, there is a large burden of disability and even
death from musculoskeletal injuries globally. This burden
and suffering are all that much more tragic because they
are so preventable, both through primary injury prevention
such as road safety and through improvements in trauma
and essential surgical care. Most of such improvements can
be made in a sustainable and affordable fashion, even in the
world’s poorest countries.
Those who have attended the ABJS/C.T. Brighton
Workshop on Trauma in the Developing World and the
readership of Clinical Orthopaedics and Related Research
at large are making considerable progress in carrying out
such real world improvements. The authors of this article
hope that some of the information presented will assist
their efforts. For example, some of the WHO publications
mentioned [10, 18, 23, 24] might be of assistance, whether
for training efforts, trauma system planning, or other such
efforts to improve the overall surgical services, especially
at primary health care facilities. Some clinicians might find
it beneficial to link up with those in the GIEESC. Likewise,
some of the data on the extent of the burden of musculo-
skeletal injuries and information on the WHA Resolution
on trauma and emergency care services might be of use in
advocacy to increase attention to this problem.
Finally, these health care issues cannot be considered
separately from broader societal and economic issues.
Although much can be improved through improved orga-
nization and planning, more extensive improvements are
hampered by economic constraints. Most countries can
spend only very small sums on health. Increasing health
expenditures is limited by overall poverty and often
by restrictions imposed by the World Bank and other
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2316 Mock and Cherian
international financial institutions as part of loan repayment
policies (formerly called structural adjustment policies).
Care of the injured would be strengthened by measures that
would allow greater funding of the health sector, including
many measures being debated currently, such as debt relief,
relaxation of restrictions on health system financing, and
promoting a more equitable world economic order, such as
by requiring the World Trade Organization proceedings
and rule making to be open and democratic [6]. In addition
to our own technical work, clinicians as individuals and as
societies of professionals need to address these bigger
global economic issues.
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